28 July 2007

Nurse K over at Crass-Pollination writes about the "Sono-Seekers." It's a totally true and frustrating abuse of the ER. Basically, these are pregnant women who come in to the ER just for the purpose of getting an ultrasound (absent any medical indication for an ultrasound).

There's an important distinction here: when there's legitimate concern for a miscarriage, I don't at all mind seeing pregnant women. A miscarriage is traumatic and scary, and the unknown prospect of losing a pregnancy is a hard thing to live with. So these folks come to the ER, because they are genuinely anxious and there is often no other venue for them to get an answer promptly. That's fine; it's what we're here for. (No, technically not an emergency, but a reasonable use of the ER, IMHO.)

But Nurse K is right on the money that there is a subset of patient who just want a picture of their baby and have either no symptoms or minimal/exaggerated symptoms to justify an ultrasound. I also have noted a tendency for these individuals to be younger (or emotionally less mature) and government-funded. Many times I have had them complain that they don't want a pelvic exam or blood tests -- they just want the ultrasound. Commonly, they have known for a while that they are pregnant, but haven't yet bothered to see an OB.

The way I handle it is designed, however, to answer the critical medical question in the most efficient manner possible, and coincidentally, happens to frustrate the sono-seekers. If the patient has previously had a documented IUP, and has an unimpressive history or findings on exam, I just check fetal heart tones. Normal FHTs do not exclude the possibility of miscarriage, but they do make it an order of magnitude less likely. I find that reasonable women (i.e. not the malingerers) generally are greatly reassured by this -- both my reassurances that their chances of keeping the baby are good, and by the simple therapeutic value of hearing their child's heartbeat. And conversely, if FHTs are absent or abnormal, then there is at least some medical indication for an ultrasound. But it annoys the malingerers to no end when I tell them that there is no medical indication for an ultrasound and discharge them with a referral to OB.

If, however, the patient has not previously had an ultrasound (and I do have to check the records, since some of the sono-seekers lie and say they have not), then I am more or less stuck with some sort of imaging to rule out an ectopic. Some might say that the presence of FHTs essentially excludes an ectopic, but I am not that brave. I do a bedside ultrasound on these folks, and I document a positive IUP and fetal heart movement for the medical record. But our bedside machine does not print out the little pictures which the sono-seekers so cherish, and I don't make a big production of "show and tell" with the exam (i.e. reviewing the fetal anatomy, speculation on gender, etc). It's a quick "Ah, here it is. Looks OK" and show's over. It's often a three-hour investment of time for the 30-second exam, and again, leaves the malingerers unsatisfied.

It sounds judgmental and even vindictive, doesn't it, this strategy to block these folks from accomplishing their goal? But it is not without reason. People who abuse the ER for some sort of secondary gain, be it narcotics, ultrasounds, or what-have-you, are tying up limited resources and diverting these resources from people who really need them. When you have ambulances being diverted from overcrowded EDs every thirty seconds, when you have waiting rooms full and patients in the hallway, it's not surprising that we get jealous of the resources we do have. Part of the way to do that is by not rewarding the bad behavior. It's easy enough for me to go ahead and order the ultrasound, or to go ahead and write the prescription for vicodin. But positive reinforcement only encourages more of the same.

Do you if you suspect that a woman is not a sono seeker give them extra time with the sono?? The reason that I ask is when I was 7 weeks pregnant, I had vaginal bleeding. I had the kindest ER dr. I was in another state miles from home. The first time it happened, I assumed I had done too much and had ran in the airport and was carrying heavy bags upstairs. Things my dr told me NOT to do. I rested and it stopped. The second time, I did absolutely nothing to bring it on. I was on business for two weeks and it happened a week later. I sat on it for a day and hoped it would stop. It didn't so I called my dr's office long distance. It was a Sunday so he wasn't open (he has since told me to page him through the hospital even if I was in another state). So I called my health insurer's nurse line. She asked me a series of questions and then directed me to immediately go to the nearest ER and they would pay for it minus my copay. Even out of state.

I arrived and I had the kindest ER dr and nurse. They treated me with compassion. I was started on an iv for fluids, had bloodwork and urine drawn. Then they had to call an US tech in from home. She was awful. She said didn't anyone tell you that this could be implantation bleeding (at 7 weeks?). Um no I was directed by the nurse for my health insurance to come in. She was awful. Wanted to fill my bladder with a foley. The nurse told her I had been drinking water. In fact my bladder was too full and I had to go empty it some. She did show me the baby had a heartbeat but was very rude.

I saw the ER dr and he wanted to keep me overnight for observation. However I HAD to be in a class the next day. Any time lost in the class was a cause for failure and had waited over a year for this class. He allowed me to leave and I was to go to class, put my feet up, then go to the hotel and order meals in. I was to do as little as possible. I promised and they gave me all the reports and I took them to my dr. It ended up that I had a fibroid that was causing the bleeding. I wish the sonographer had been more compassionate and the nurse for me, lit in to her like you wouldn't believe when that happened. Oh and the sonographer told the dr that I was being uncooperative when I requested not to fill my already full bladder with a foley. Thank God the ER dr and nurse told her she was nuts.

I was just curious if you gave everyone the standard treatment, or if you really suspect that they are not a sono seeker the full range of tests. BTW, they never used a doppler. That heartbeat was music to my ears during the sono. No I didn't get a pic, but I didn't ask either. The bleeding eventually resolved and I have a healthy 2 year old now.

Bravo to not satisfying the sonoseekers. You left out only one fact that I often witnessed. These "symptoms" often occur in the middle of the night. As a registered OB/Gyn sonographer, I did more than my share of 2am STAT ultrasound exams to "rule out ectopic" or "suspected fetal demise." You were absolutely correct in your summation of their "situation" (younger or less mature, etc.) The sonoseekers I encountered typically had several people in the room with them, and wanted all to come back to Ultrasound with them. I normally allowed only one guest to accompany them. There was no show and tell, no gender determination or picture given. I simply explained to them that this had been deemed and emergency exam by the physician due to their symptoms. My task was to determine the condition of their pregnancy. While some may think this callous, you must understand that we typically had worked a 10 hour day, perhaps already been called in for other emergency exams, and had a 10 hour day ahead of us tomorrow.

To pe mommy, I apologize for your experience. It is the repeated occurence of the above mentioned sonoseekers that cause the healthcare professional to become jaded. If I was able to determine that the patient was not a "seeker" (normally very easy to spot) then I would take extra time, show you the baby, and help to reassure you. Many women in your situation feel that it is their fault that this is happening. While it is important to follow your Dr's instruction, the guilt that "It's all my fault" brings in unbearable and counterproductive. Again, I apologize to you from our profession. Many of us went into Sonography due to our desire to serve, and compassionate manner. Some of us lose sight of that during 10 hour days with 20 patients on the schedule and Dr's offices calling and forcing you to do an exam today, simply because they can. (Interestingly these are often the same Doctors that I call for an appointment and can't be seen for 2-6 weeks.) I am not excusing the behavior of the sonographer, just trying to explain it. I hope your pregnancy is smooth sailing from now on.

Yes, I am generally very nice and sympathetic to the "real" patients. How much time I spend is more dependent on how busy I am, but I'll usually take a second to explain what I am looking at. I think the sonographer below eloquently explains why they get a little grumpy.

Nurse K,ER docs doing ultrasound is only beginning to catch on nationwide. Most residents are trained in doing it now, but there are still obstacles in implementing it in community ERs.

Isles,Yes, I can prevent the patient from seeing the screen altogether. I don't want to be a TOTAL dick, though.

Thanks guys, I was just curious. My daughter is now 2 years old. I actually got sick of sonograms with her. I had them every week after 26 weeks for chronic htn w/superimposed severe pih. I never ever thought I would say that.

I am planning on getting pregnant again in the fall and suspect that I will have bleeding problems again as I have bleeding problems ever since my last daughter was born. But I have an awesome obgyn now. He was new to me when I started with my daughter.

It would piss me off to have someone come in giggling and texting and inviting all their friends and it was 2am too. I can assure you I was not like that at all, in fact I was all by myself.

Nurse K,ER docs doing ultrasound is only beginning to catch on nationwide. Most residents are trained in doing it now, but there are still obstacles in implementing it in community ERs.

A couple of our newer docs/recently graduated residents I've seen bust out the U/S for various reasons, including to diagnose gallstones quickly when it's not clear if a problem is gallbladder or cardiac.

I do a bedside US on most, if not all, of my pregnant pts to at least document FHTs. If there's ANY question about the viability or health of the pregnancy, I'll do more...often a transvaginal (3 times this month we've caught ectopics that the "official" scan by radiology missed.)

As for discouraging the "sonoseekers" (I like that term!), I NEVER give out images. NEVER. And yes, it's very easy to arrange the US so the pt can't see the screen.

I tell people 2 reasons for not giving out images (or telling gender):

1) straight up, b/c some people come for that only, and instead of "choosing" who I do and don't give them to, I've chosen to just NOT give them

and 2) I'm not an OB. My US machine is not as good as an OBs. So, anything I see on there I use to rule out emergencies, and nothing else. If I give the image out, and it shows something I didn't see b/c I'm not trained to see it (cardiac defect?), then I am in effect telling the patient that "everything's fine" and she may not get another US...the one that diagnoses the problem; now I'm at fault for missing it.

I tell them "your baby appears to be in the right place, and it's heart is beating appropriately. You still need to see your OB and have an official US to make sure it's developing correctly."

I hope one of 2 things is happening: either your docs are accredited to do GB US, or, they take a quick look to quickly triage the pt, sending them for a formal US if they're concerned, but NOT fully ruling out stones if they don't.

If they're not accredited, then their US is legally worthless and should not be used for diagnosis. Seeing stones and then sending for the formal to eval for cholecystitis is fine; NOT seeing stones and being comfortable that you have another diagnosis is ok (but the US should not be used in the final decision making); telling a patient "I, who am not certified to do this, do not see a problem, so you can go home" is medicolegally a bad thing.

Yes, it's confusing...why do it if you can't use it in your decision making? It's why I typically don't.

Nurse K: EP's (versus "ER docs") routinely do bedside US to diagnose an IUP. More recent graduates from EM residencies are usually trained & credentialed in this skill set. EP's that have been practicing awhile can take a course to get credentialed. We perform US studies in a focused and limited fashion (e.g. is there an IUP, FAST exams, obvious cholecystitis resulting in immediate surgical consult versus waiting for formal US by radiology, etc...).

Isles: I agree with Shadowfax that turning the screen away from the patient would be a dick move. And mean.

Tired Sonographer: Do your job and quit the whining. We are all overworked. Get over yourself. And your inability to get an appt with your PCP for 2-6 weeks has absolutely nothing to do with their need for a same day US. Poor you. Poor bitter you. Quit your job if you are tired of being on call. As for limiting the number of people who accompany the patient into the exam room -- what gives you the right to make this call? Do you change the amount based on the patient's race or appearance? Do you change the amount based on your judgmental perspective of whether or not the patient is a "seeker?" Do you change your policy for patients you like? People who make policy to suit themselves rather than just doing what is best for the patient are jerks. You are a jerk.

Hibgia: You choose never to give pictures to your patients. I can respect that but wonder why a quick press of the print button (assuming the printer is working) is such a hurdle. Why bother to choose who to give pics to and who not to? Just give pics to all who want one. Trust me -- it will make you feel better by making them feel better regardless of their motivation for coming to the ED. Also, the presence of some "defect" on the image does not make you liable or responsible for same. Unless you are otherwise credentialed your liability ends at IUP versus non-IUP.

You're right, it would make me feel good to make the patient feel good. However, you imply that I choose who to give them to...nope, exactly the oppositve, I have chosen not to choose, and just not to do it. And yeah, the liability thing really isn't that realistic, just a thought.

It's not necessarily about discouraging them from coming to the ED for a US/picture (although that's a part of it), but to ENcourage them to get a "real one." If all of their expectations are met in the ED (your baby's healthy, it's a girl, and here's her picture), then a significant number will see that as their prenatal care...not a good thing for the patient (either of them).

I do for them what directly helps the baby...prenatal vitamins if they're not on them, r/o ectopic, make sure there's a heartbeat, counseling about drugs, smoking, and the need for good prenatal care. Giving a picture may help them emotionally, but then hurt them in the long run.

I am not pushing for determining the sex of the baby or anything beyond a diagnosis of IUP versus ectopic.

And I agree that proper prenatal care should take place outside the ED. You make an excellent point. But I respectfully disagree that giving them a picture will cause any harm when properly counseled to f/u for all the other stuff you mention.

However, I just walked out of bed #8 in my ED after doing a TVUS to diagnose an IUP in a woman with threatened miscarriage @ seven weeks gestation. TVUS showed IUP with good cardiac activity but patient had lots of bleeding and pelvic cramping similar to her menstrual cramps. I gave her a picture (they accepted my offer of same) but wondered if it was appropriate as I suspect she will abort in the next 72 hours. Made me wonder if it was cruel to offer...

I think telling someone they've miscarried or probably will miscarry is the single worst thing I have to do. For some reason, that affects me more than telling someone their father/grandfather/etc has died.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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